Travelers' Diarrhea

Travelers' diarrhea (TD) is the most common illness affecting travelers. Each year many travelers develop diarrhea. TD usually occurs within the first week of travel. However, it may occur at any time while traveling. It may even occur after returning home. The most important risk factor is where you are going. High-risk places are the developing countries of:

  • Latin America.

  • Africa.

  • The Middle East.

  • Asia.

High risk people include young adults and those with:

  • Transplants.

  • HIV infections.

  • Medicine that suppresses the immune system.

  • Inflammatory-bowel disease.

  • Diabetes.

  • H-2 blockers or antacids.

Attack rates are similar for men and women. The primary source of TD is eating or drinking food or water tainted with feces (stool or bowel movements).

CAUSES

Infectious agents are the primary cause of TD. Germs cause almost 80% of TD cases. The most common germ produces:

  • Watery diarrhea with cramps.

  • Low-grade or no fever.

There are many other bacterial, viral and parasitic pathogens (disease causing "bugs").

SYMPTOMS

Most TD cases begin suddenly. Symptoms include stool that is increased in:

  • Frequency.

  • Volume.

  • Weight.

Altered stool consistency also is common. Typically, you have four to five loose or watery bowel movements each day. Other common symptoms are:

  • Nausea.

  • Vomiting.

  • Diarrhea.

  • Abdominal cramping.

  • Bloating.

  • Fever.

  • Urgency.

  • Malaise.

Most cases are not dangerous. Most cases go away in 1-2 days without treatment. TD is rarely life threatening. 90% of cases resolve within 1 week. 98% resolve within 1 month.

PREVENTION

  • Avoid foods or beverages purchased from street vendors in high risk countries.

  • Avoid food from places where unclean conditions are present.

  • Avoid raw or undercooked meat and seafood.

  • Avoid raw fruits (e.g., oranges, bananas, avocados) and vegetables unless you peel them yourself.

  • If handled properly, well-cooked and packaged foods usually are safe. Foods associated with increased risk for TD include:

  • Tap water.

  • Ice.

  • Unpasteurized milk.

  • Dairy products.

  • Safe beverages include:

  • Bottled carbonated beverages.

  • Hot tea or coffee.

  • Beer.

  • Wine.

  • Boiled water.

  • Water treated with iodine or chlorine.

ANTIBIOTICS ARE NOT RECOMMENDED AS PREVENTION

  • CDC (Centers for Disease Control) does not recommend antimicrobial drugs (medicine that kill germs) to prevent TD. Several studies show that Pepto-Bismol® taken as either 2 tablets 4 times daily, or 2 fluid ounces 4 times daily, reduces the incidence of travelers' diarrhea. People that should avoid Pepto-Bismol® include those who are:

  • Pregnant.

  • Allergic to aspirin.

  • Taking anticoagulants medicine (probenecid, methotrexate).

  • Be informed about potential side effects, in particular about temporary blackening of the tongue and stool, and rarely ringing in the ears. Because of potential adverse side effects, preventative Pepto-Bismol® should not be used for more than 3 weeks.

  • Some antibiotics taken in a once-a-day dose are 90% effective at preventing travelers' diarrhea. However, antibiotics are not recommended as prevention. Routine antimicrobial prophylaxis increases your risk for:

  • Adverse reactions.

  • Infections with resistant organisms.

  • Antibiotics can increase your susceptibility to resistant bacterial pathogens and provide no protection against either viral or parasitic pathogens. This can give travelers a false sense of security. As a result, strict adherence to preventive measures is encouraged. Pepto-Bismol® should be used as an extra effort if prophylaxis is needed.

TREATMENT

  • TD usually is a self-limited disorder. It gets well without treatment. It often goes away without specific treatment. Oral re-hydration is often helpful to replace lost fluids and electrolytes. Clear liquids are routinely recommended for adults. You may be helped with antimicrobial therapy if you develop three or more loose stools in an 8-hour period, especially if associated with:

  • Nausea.

  • Vomiting.

  • Abdominal cramps.

  • Fever.

  • Blood in stools.

  • Antibiotics usually are given for 3-5 days. Pepto-Bismol® also may be used as treatment. Take one fluid ounce, or two 262 mg tablets every 30 minutes, for up to 8 doses in a 24-hour period. This can be repeated on a second day. If diarrhea persists despite therapy, you should be evaluated by a caregiver and treated for possible parasitic infection.

  • Because drug resistance is a continuing problem and may vary from country to country, professional assistance should be looked for if problems persist.

  • Antimotility agents (loperamide, diphenoxylate, and paregoric) mostly reduce diarrhea by slowing down the passage of food and drink in the gut. This allows more time for absorption. Some persons believe diarrhea is the body's defense mechanism to minimize contact time between gut pathogens and lining of the bowel. In several studies, antimotility agents have been useful in treating travelers' diarrhea by decreasing the duration of diarrhea. However, these agents should never be used by persons with fever or bloody diarrhea because they can increase the severity of disease by delaying clearance of causative organisms. Because antimotility agents are now available over the counter, their improper use is of concern. Complications have been reported from the use of these medicines such as:

  • Toxic megacolon.

  • Sepsis.

  • Disseminated intravascular coagulation.

SEEK IMMEDIATE MEDICAL CARE IF:

  • You are unable to keep fluids down.

  • Vomiting or diarrhea becomes persistent.

  • Abdominal (belly) pain develops or increases or localizes. (Right sided pain can be appendicitis and left sided pain in adults can be diverticulitis).

  • You develop an oral temperature above 102° F (38.9° C), or as your caregiver suggests.

  • Diarrhea becomes excessive or contains blood or mucous.

  • Excessive weakness, dizziness, fainting or extreme thirst.

  • Checking weight 2 to 3 times per day in babies and children will help verify adequate fluid replacement. Your caregiver will tell you what loss should concern you or suggest another visit to your personal physician.

  • Record your weight or your child's weight today. Compare this to your home scale and record all weights and time and date weighed. Try to check weight at the same times every day. Bring this chart to your caregivers if you or your child needs to be seen again.

FOR MORE INFORMATION

Travelers should consult with a caregiver before departing on a trip abroad. Information about TD is available from:

  • Your local or state health departments.

  • World Health Organization (WHO).

Other information that may be of interest to travelers can be found at the CDC Travelers' Health homepage at http://www.cdc.gov/travel.